Appeals court rolls back Ohio gender affirming care law
The appeal surrounded the ban on gender-affirming pharmaceutical medical care for minors diagnosed with gender dysphoria. The law bans transgender surgeries and hormone therapies for minors unless they are already receiving such therapies and it is deemed a risk to stop by a doctor.
The Court ruled Tuesday that the trial court erred in its favorable ruling on the law saying that the trial court did not apply 'rational basis review' to parents' claim that they had a right to provide care to their child that has been recommended by a medical professional.
'Such a sweeping and inflexible ban on parents' ability to access medical care for their children is not narrowly tailored to advance the state's articulated interest: the protection of children. Applying strict scrutiny. (The law) facially violates Ohio parents' right to substantive due process under the Due Course of Law Clause of the Ohio Constitution,' Judge Carly Edelstein wrote in her decision.
Edelstein added that the law violates the Health Care Freedom Amendment to the Ohio Constitution because it puts medical professionals in danger of discipline for providing care that is 'in accordance with the standards of care and guidelines widely accepted in the professional medical community,' and care that is being requested by parents on behalf of their children.
Ohio Attorney General David Yost immediately issued a statement on the court's decision saying he would continue to fight for the ban.
'This is a no brainer – we are appealing that decision and will seek an immediate stay. There is no way I'll stop fighting to protect these unprotected children,' Yost wrote.
Yost accused the court of going against what Ohio voters wanted when the law was passed and lawmakers agreed they wanted to limit medical inventions for minors.
Copyright 2025 Nexstar Media, Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
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A 67-Year-Old Woman With an Incidental Rectal Mass
Editor's Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians, but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please email us at ccsuggestions@ with the subject line "Case Challenge Suggestion." We look forward to hearing from you. Background and Presentation A 67-year-old woman initially presented to the hospital more than 4 years ago and was admitted for management of a hypertensive emergency and acute kidney injury. Her course was complicated by atrial fibrillation, acute cerebrovascular accident, and worsening constipation. She was subsequently transferred to the long-term care ward because it was determined that she is incapacitated and unable to make healthcare decisions without assisted consultation; thus, she was deemed unsafe for discharge. She is under a conservatorship through a probate court. The patient has been receiving routine screenings that would typically be completed as an outpatient, such as mammograms and DEXA, during her very prolonged hospital stay. Interpretation of a recent CT scan for evaluation of abdominal pain revealed an extensive stool burden and incidentally noted a questionable 1.3-cm round density in the rectum, possibly representing a stool ball, although an underlying lesion could not be excluded (Figure 1). The inpatient gastroenterology team was consulted for further recommendations. Figure 1. Round density within the rectum (white arrow) measuring 1.3 cm. The patient had no complaints, although she had difficulty providing an accurate history. Per the nursing staff, she can go 4-5 days without having a bowel movement and she often has hard stool. She was taking laxatives, including polyethylene glycol 17 g twice daily and senna glycoside, two tablets twice daily. She occasionally also has loose stool. Upon further chart review, her last colonoscopy was 4 years ago and revealed stool throughout the colon. There were no colonic polyps or mass noted. She reported not having any unintentional weight loss, rectal bleeding, dysphagia, heartburn, nausea, or vomiting. Physical Examination and Workup The patient has a temperature of 98.6 °F, blood pressure of 123/65 mm Hg, heart rate of 77 beats/min, and respiratory rate of 18 breaths/min. She is alert and cooperative. Her eyes are nonicteric. Her abdomen is soft, nontender, and nondistended. No supraclavicular lymphadenopathy is noted. She has no temporal or clavicular muscle wasting and no lower-extremity edema. Laboratory testing results are: Hemoglobin: 12.5 g/dL (reference range, 12-16 g/dL) Mean cell volume: 80 fL (reference range, 80-100 fL) Alkaline phosphatase: 50 U/L (reference range, 39-113 U/L) Aspartate aminotransferase: 19 U/L (reference range, 17-35 U/L) Alanine aminotransferase: 20 U/L (reference range, 8-39 U/L) Total bilirubin: 1.0 mg/dL (reference range, 0.1-1.2 mg/dL) Albumin: 3.8 g/dL (reference range, 3.8-5.3 g/dL) Blood urea nitrogen: 20 mg/dL (reference range, 8-24 mg/dL) Creatinine: 1.50 mg/dL (reference range, 0.60-1.20 mg/dL) Next Steps to Consider The most appropriate next step in management would be a colonoscopy for further evaluation and possible biopsy of the suspected rectal mass. 64Cu-dotatate PET is an imaging technique that provides high-quality images for detection of neuroendocrine tumors (NETs). This is an excellent imaging tool with high sensitivity (90.9%) and specificity (96.6%) for detecting NETs.[1] However, a colonoscopy would be the preferred next step in this situation, given the location of the mass in the rectum and the opportunity to obtain definitive biopsy specimens. Rectal NETs typically are associated with an excellent prognosis, although the rate of metastasis depends on tumor size. For example,[2] lesions ≤ 1 cm have only a 3% rate of metastasis, while tumors 11-19 mm have a 66% rate of metastasis. This rate further increases to 73% for tumors ≥ 2 cm. Rectal NETs are typically resected. The resection technique depends on tumor size. For lesions ≤ 1 cm, endoscopic mucosal resection (EMR) is typically the preferred method. Given the submucosal nature of the tumor, a standard cold snare or hot snare polypectomy would not be sufficient. Band ligation and underwater EMR are the preferred EMR methods per the 2023 American College of Gastroenterology guidelines on subepithelial lesions.[2] For lesions > 1 cm, a surgery referral is warranted. Endoscopic submucosal dissection also may be considered for these cases.[2] Gastrointestinal NETs (GI-NETs) can occur anywhere along the digestive tract, from the esophagus to the rectum, but they more commonly occur in the midgut (ileum, appendix).[3] They are also known as carcinoid tumors. GI-NETs are typically diagnosed in individuals in their seventh decade, but they can occur at any age and incidence is similar between males and females. Symptoms can include abdominal pain or cramping, diarrhea, rectal bleeding or blood in the stool, and flushing, among others. Carcinoid syndrome occurs when GI-NETs release excessive amounts of bioactive hormones and is associated with metastasis, particularly to the liver.[3] Carcinoid syndrome is characterized by systemic symptoms such as flushing, diarrhea, and wheezing. Serum chromogranin A (CgA) is a nonspecific biomarker that may be useful during the investigation for gastroenteropancreatic NETs, although it has limited use in the evaluation of colorectal NETs because it is rarely elevated and does not accurately reflect tumor burden. CgA elevations have been noted with various gastrointestinal and nongastrointestinal comorbidities, ranging from atrophic gastritis and pancreatitis to renal insufficiency, chronic bronchitis, and hyperthyroidism. Certain medications can increase chromogranin levels as well, including proton pump inhibitors (which should be held 7 days prior to CgA testing) and histamine-2 receptor antagonists (which should be held 24 hours prior to CgA testing). Strenuous exercise or food intake prior to testing also can affect levels. These factors explain the low specificity of CgA testing for NETs.[4] This would not be the best next step for evaluation of an incidentally noted rectal mass on CT. CT-guided biopsy also would not be the best next step in management for this patient. Given the finding of a possible rectal mass, the patient should undergo colonoscopy for further evaluation and possible sampling of this mass. The patient was scheduled for a colonoscopy. She underwent a 2-day bowel preparation given her significant history of constipation and extensive stool burden noted on CT. The colonoscopy revealed a dilated colon and brown pigmentation of the colonic mucosa, consistent with melanosis coli (Figure 2). She had a redundant colon, prone to extensive looping of the colonoscope. Figure 2. Colonoscopy showing a dilated colon and brown pigmentation of the colonic mucosa, consistent with melanosis coli. Additionally, a round, subepithelial lesion was found in the rectum, with a dimpled appearance and a central erosion (Figure 3). Figure 3. Colonoscopy showing a round, subepithelial lesion in the rectum with a dimpled appearance and central erosion (yellow arrow). Establishing the Diagnosis The most appropriate next step to establish the diagnosis would be a tunneled "bite-on-bite" forceps biopsy. Given the subepithelial nature of the tumor, a standard mucosal cold forceps biopsy would not provide tumor tissue for diagnosis. Thus, an endoscopist would have to take a forceps biopsy and then take several additional samples in the same location to obtain deeper levels of tissue. NETs are typically found in the submucosa. A cold snare polypectomy would not be appropriate because this is typically done for standard colon polyps, which are mucosal lesions. Given the submucosal nature of a rectal NET, endoscopic removal should be done via EMR or endoscopic submucosal dissection. Typically, endoscopic resection of rectal NETs is suggested for small (< 1 cm) tumors, whereas larger tumors > 1 cm should undergo endoscopic submucosal dissection or surgical resection.[2] Similarly, hot snare polypectomy would not be appropriate because this is typically done for standard colon polyps, which, again, are mucosal lesions. A tunneled 'bite-on-bite' biopsy was obtained. Pathology revealed multiple fragments of unremarkable rectal mucosa, with the exception of two fragments in which a submucosal proliferation of small, uniform glands were positive for synaptophysin, chromogranin, and insulinoma-associated protein 1 (INSM1). The proliferative activity index by MIB-1 (Molecular Immunology Borstel 1) is less than 1%. Explanation Pathology revealing a submucosal proliferation of small, uniform glands positive for synaptophysin, chromogranin, and INSM1, with a proliferative activity index by MIB-1 of less than 1%, is consistent with a well-differentiated NET. A poorly differentiated NET typically has a proliferative activity index of 20% or greater.[5] Common immunohistochemical markers for a schwannoma include S100 protein and glial fibrillary acidic protein.[6] Common immunohistochemical markers for a gastrointestinal stromal tumor include CD117 (c-KIT) and discovered on GIST-1 (DOG-1).[7] Because of its high sensitivity (90.9%) and specificity (96.6%) for detecting NETs,[1] a 64Cu-dotatate PET scan was performed to confirm diagnosis. PET findings did not show any metastatic disease. Management Decisions A surgery referral would be the best next step in management. Rectal NETs typically have an excellent prognosis, although the rate of metastasis depends on tumor size, with rates ranging from 3% (≤ 1 cm) to 66% (11-19 mm) to 73% (≥ 2 cm).[2] Rectal NETs are typically resected. The resection technique depends on tumor size. For lesions ≤ 1 cm, EMR is typically the preferred method of resection. Given the submucosal nature of the tumor, a standard cold snare or hot snare polypectomy would not be sufficient. As discussed, American College of Gastroenterology guidelines recommend band ligation and underwater EMR as the preferred EMR methods for subepithelial lesions.[2] For lesions > 1 cm, a surgery referral is warranted. Endoscopic submucosal dissection also may be considered for these cases.[2] 64Cu-dotatate PET scanning is useful for assessing for metastatic disease, which was not seen in this patient. Clinical/imaging surveillance would not be the best next step in management, as rectal NETs > 1 cm have a rate of metastasis of greater than 60%. Thus, resection is indicated if the patient is deemed to be a procedural candidate and if this is within the patient's goals of care. Underwater EMR is an excellent option for rectal NETs < 1 cm, but this patient's tumor is > 1 cm. Starting a somatostatin analog (octreotide or lanreotide) would not be the best next step of management for this patient with a solitary, nonmetastatic rectal NET. These medications are certainly a consideration in patients with NETs, particularly those with metastatic disease, and octreotide is used in carcinoid syndrome. The decision to start octreotide or lanreotide is typically made by the hematology-oncology service. Data suggest an antiproliferative effect; for example, the CLARINET trial (2014) — a randomized, double-blind study comparing lanreotide with placebo — suggested significantly prolonged progression-free survival among patients with metastatic enteropancreatic NETs grade 1-2 (Ki-67 < 10%).[8] One caveat is that the hazard ratios had wide confidence intervals for patients with hindgut tumors (which include rectal NETs), possibly attributed to the smaller sample size of this subgroup. In consultation with her conservatorship, the patient discussed resection options with both the surgery team and the advanced gastroenterology team. Owing to the size of her lesion (1-2 cm) and lack of metastasis, the decision was made to perform an endoscopic mucosal dissection procedure, which went well, without any complications. Explanation Type 1 gastric NETs are associated with atrophic gastritis, which is commonly seen in states of chronic inflammation such as chronic Helicobacter pylori gastritis or autoimmune gastritis. Patients with autoimmune gastritis have antibodies against intrinsic factor and/or parietal cells. Patients with atrophic gastritis typically have achlorhydria (an absence of hydrochloric acid secretion in the stomach). This leads to hypergastrinemia as a physiologic response, which, in turn, leads to enterochromaffin-like cell hyperplasia and can progress to type 1 gastric NET formation. These tumors typically are small, multiple, and have low metastatic potential. Type 2 gastric NETs are seen in patients with multiple endocrine neoplasia type 1 syndrome. Patients with this syndrome often have a pancreatic tumor that can secrete insulin, vasoactive intestinal peptide, glucagon, or gastrin. When a pancreatic neuroendocrine tumor secretes excessive gastrin, this is known as Zollinger-Ellison syndrome. Patients with type 2 gastric NETs typically have high gastrin levels, which lead to high levels of gastric acid secretion (as opposed to the achlorhydria seen in those with type 1 gastric NETs). Type 3 gastric NETs are sporadic and are more likely to be metastatic. Unlike type 1 and 2 gastric NETs, type 3 gastric NETs are not associated with hypergastrinemia. Rectal NETs are thought to have the best prognosis among NETs, especially small (< 1 cm) rectal NETs, which have a low (3%) rate of metastasis and can be endoscopically resected.
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is a senior correspondent at Vox, where he focuses on the Supreme Court, the Constitution, and the decline of liberal democracy in the United States. He received a JD from Duke University and is the author of two books on the Supreme Court. The Supreme Court ruled on Monday that the Trump administration may fire more than half of the Department of Education's workforce — mass terminations that, in Education Secretary Linda McMahon's words, are 'the first step on the road to a total shutdown' of the entire department. The Court's decision in McMahon v. New York, was handed down on the Court's 'shadow docket,' a mix of emergency motions and other expedited matters that the justices often decide without full briefing or oral argument. As is often the case in shadow docket decisions, none of the Republican justices explained their decision. Justice Sonia Sotomayor wrote a dissent, which was joined by both of her fellow Democratic justices. SCOTUS, Explained Get the latest developments on the US Supreme Court from senior correspondent Ian Millhiser. Email (required) Sign Up By submitting your email, you agree to our Terms and Privacy Notice . This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Technically, the Court's decision in McMahon is temporary — it permits the Trump administration to fire most of the Education Department's workers while this lawsuit is still pending in federal court. But it is far from clear how the Education Department could unwind a decision to fire more than half of its over 4,000 employees. The McMahon decision is particularly unnerving because it suggests that President Donald Trump is allowed to 'impound' federal spending — unilaterally refusing to spend money or to continue federal programs that are mandated by an act of Congress. While McMahon does not explicitly authorize impoundment, it allows the Trump administration to fire so many federal workers, in so many key roles, that the practical effect is to cancel entire federal programs. Impoundment is unconstitutional, and even some of the Court's Republicans have previously said as much. As Justice Brett Kavanaugh wrote in a 2013 opinion when he was still a lower court judge, 'even the President does not have unilateral authority to refuse to spend the funds. Instead, the President must propose the rescission of funds, and Congress then may decide whether to approve a rescission bill.' If the president had the power to impound funds, he could effectively cancel any federal law by cutting off the spending authorized by that law or cutting off the money necessary to enforce it. Until recently, the argument that the president may impound funds was considered so ridiculous that even Republican legal luminaries rejected it out of hand. As future Chief Justice William Rehnquist wrote in a 1969 Justice Department memo, 'it is in our view extremely difficult to formulate a constitutional theory to justify a refusal by the President to comply with a congressional directive to spend.' The plaintiffs in McMahon, a coalition of states and a school district which stand to lose funding because of Trump's mass firings, argued that only Congress may abolish an entire federal department, or otherwise cancel federal spending programs that are mandated by federal law. And, as Sotomayor explains in her dissent, the mass firings her Republican colleagues just greenlit effectively destroy many such programs. The Trump administration, for example, seeks to fire 'the entire Office of English Language Acquisition, which Congress tasked with administering the Department's 'bilingual education programs.'' It also seeks to eliminate 'all employees within the Office of the General Counsel that specialize in K–12 education funding and IDEA grants; 7 of 12 regional divisions of the Office of Civil Rights; most of the Federal Student Aid office responsible for certifying schools so that their students can receive federal financial aid; and the entire unit of the Office of Special Education and Rehabilitative Services charged with providing technical assistance and guidance on complying with' the Individuals with Disabilities and Education Act. All of these firings, moreover, are the first step in implementing a Trump Executive Order with a section entitled 'Closing the Department of Education and Returning Authority to the States.' Thus, the Republican justices appear to have ruled that Trump may do indirectly what the Constitution forbids him from doing directly. Even if they will not ultimately permit him to impound the Education Department's funding — thus closing the department by permitting Trump to strip it of all of its money — it appears that the GOP-controlled Court will permit Trump to achieve the exact same outcome by firing the department's employees. McMahon solves a mystery that is less than a week old Last week, in Trump v. American Federation of Government Employees (AFGE), the Supreme Court issued a similar decision reinstating a different Trump executive order which called for mass firings. That order required federal agency leaders to come up with aggressive plans to fire agency employees, but did not provide many details on who will be fired. Significantly, the Court's decision in AFGE split the three Democratic justices. While Justice Ketanji Brown Jackson wrote a dissent saying that Trump cannot engage in a grand restructuring of the federal workforce without congressional approval, Sotomayor wrote a concurring opinion arguing that judicial intervention in the AFGE case is premature. According to Sotomayor, while the executive order at issue in AFGE required agencies to come up with plans for mass firings, 'the plans themselves are not before this Court, at this stage, and we thus have no occasion to consider whether they can and will be carried out consistent with the constraints of law.' Sotomayor, in other words, would have waited for the agencies to release their plans, and then she would have determined whether any of these plans make such deep cuts that they amount to something like an unconstitutional impoundment. The McMahon case, by contrast, presented the same issue that Sotomayor anticipated in her AFGE concurrence. Secretary McMahon has already come up with a plan to fire more than half her department's employees, and that plan was before the Supreme Court. So Sotomayor and her colleagues could determine whether any of these cuts are so deep that they effectively eliminate federal programs mandated by Congress. Now that this issue was properly before the Court, however, Sotomayor's Republican colleagues appear to have come out in favor of impoundment. So why did the Republican justices reach this conclusion? Because the justices in the majority did not explain their decision in McMahon, it is impossible to determine with any certainty why they ruled in favor of Trump. But Sotomayor's dissent summarizes the Trump administration's legal arguments, and thus offers some window into why this decision may have come down the way that it did. The administration's primary argument was that the plaintiffs in this case lacked 'standing' to challenge the mass firings — before a party can bring a federal lawsuit, they must show that they were injured in some way by the defendant they hope to sue. Trump's lawyers argued that the plaintiffs in this case 'failed to demonstrate an 'actual or imminent' harm fairly traceable to' Trump's executive order. But, as Sotomayor argues, this 'claim is belied by both the record and common sense.' The plaintiffs named several specific injuries that have already resulted from terminations that have already taken place. A state college, for example, 'did not receive recertification for one of its campuses in time for the start of the spring 2025 semester' because the Education Department office that provides that certification was so understaffed. Because of this failure, 'the school was forced to forgo admitting students eligible for federal financial aid, and the total enrollment for the term was less than one-fifth of the expected size, costing the college lost tuition funds.' The Trump administration also argued that its decision to fire many Education Department employees may only be challenged at the Merit Systems Protection Board, a defunct agency that is currently unable to do anything at all because it lacks the quorum it needs to operate. And it argued that the lower court's order swept too broadly. Because the Republican justices did not explain their decision, however, we cannot know which, if any, of these arguments persuaded them. These justices' failure to explain themselves may also have needlessly sabotaged the plaintiffs' case. If the Republican justices believed that these plaintiffs lack standing, for example, their lawyers could have found a different plaintiff or filed an amended complaint alleging additional injuries resulting from the mass firings. If the GOP justices believed the lower court order halting the firings was too broad, that court might still issue a narrower order.
